linkAges is a new, community-based, multigenerational network designed to engage and activate existing resources within communities to improve the health and wellbeing of seniors and family caregivers.
We know that quality of life and social connections are key determinants of health. For example, seniors who are lonely have a 45% increased mortality rate at 6 years compared to seniors who are not lonely. They have twice the rate of loss of ability to perform normal activities of daily living, which contributes to higher institutional care rates. While it is widely recognized that medical interventions prevent only 10% of premature death, social determinants, including loneliness and isolation, are ignored or not effectively addressed by the current care model.
In an unprecedented commitment by a large health system, linkAges partners the Palo Alto Medical Foundation, one of the region’s largest providers of primary and specialty care, with local nonprofits, neighborhood associations, faith-based organizations, and businesses to offer a community-based response to address non-medical determinants of health and support aging in place.
The linkAges system has the following components:
The linkAges TimeBank is one component of the emerging linkAges system and is being used as a mechanism to connect neighbors and community members across all ages. Members of the linkAges TimeBank, including seniors and family caregivers, can address personal needs through exchanges with other members that focus on their interests and skills and explore new possibilities for meaningful engagement in their communities. In the TimeBank, everyone’s time and services are valued equally.
How can we spot meaningful shifts in the social and physical health of seniors before it’s too late? linkAges Connect attempts to do this by utilizing passive signals in the home (such as utilities/water usage patterns) to prevent acute care incidents and support well-being by detecting indicators that something might be wrong so that an appropriate responder/caregiver can receive a timely alert.
This is a crowd-sourced resource referral list that specifically addresses the needs and interests of seniors and family caregivers. linkAges List will include listings of community resources, services and businesses supported by reviews of personal user experiences.
A central component of the linkAges system, the Profile captures social wellbeing characteristics of individuals to personalize other system components so that users receive individually relevant system messages and services.
Why linkAges and Why now?
With Baby-Boomers now turning 65, America faces an unprecedented demographic shift that will force the health care industry to rethink how we address the needs of older adults. To effectively address the health of populations under the Affordable Care Act, the next-generation health system must reinvent itself as a community health partner, not just a sick-care delivery system. linkAges disrupts the traditional business model of fee-for-service sick care delivery and addresses those social determinants of health that are external to today’s health care delivery systems by creating a broad, community-based model to support successful aging in place.
PAMF’s David Druker Center for Health Systems Innovation launched the linkAges program and is deploying it in the community by engaging community members and individuals and organizations across diverse sectors who understand the importance of responding collectively to support aging in place. linkAges is designed to be scalable and readily replicated and adaptable to meet local needs and resources.
linkAges in the Community
Earlier this year, the linkAges pilot was formally initiated in the city of Mountain View, California, which was chosen because it is home to a population of diverse ethnicities and incomes, active partner agencies, a supportive City Council, strong neighborhoods and faith-based communities, and a significant senior population. The goal of linkAges is to have a toolkit available for replication and adoption by diverse organizations that includes the linkAges platform, evaluation findings, and a community engagement model.
Scalable impact is key to the vision for linkAges as a system that will effectively support aging in place through cross-sector partnerships and community activation. It is our hope that this project will serve as a cost-effective solution to fulfilling the growing need for support systems that can empower vulnerable seniors to age in place with enhanced health, independence, and quality of life.
The Innovation Center’s diverse team embodies passion, talent, spirit and drive. Representing physicians, scientists, designers, social entrepreneurs, business people, and more, each individual is committed to making the world a better place by harnessing innovative spirit and methods.
Paul has directed innovative health information technology programs in healthcare organizations, industry, and national policy-making committees for over 30 years. He directed a research group at Hewlett Packard Laboratories in the 1980s that used knowledge-based technology to create intelligent electronic health record (EHR) systems for physicians. In 1994, he led the implementation of the EHR at Northwestern, which was awarded the Nicholas E. Davies Award for Excellence in Computer-based Patient Records Implementation. Joining PAMF in 1998, he directed the implementation of the EHR at PAMF, the first large medical group practice in California to use an EHR. And in 2001, PAMF collaborated with Epic to create the MyChart patient portal and was the first in the country to implement it.
Over the past 15 years, Paul has been working to accelerate the nation’s adoption and effective use of health information technology. Paul is vice chair of the U.S. Department of Health and Human Services Health Information Technology Policy Committee, and chair of its Meaningful Use workgroup. He is a member of the National Committee on Vital and Health Statistics (NCVHS) and co-chairs its Quality subcommittee. He chairs the National Quality Forum’s (NQF) Health Information Technology Advisory Committee, and chairs the Robert Wood Johnson Foundation’s National Advisory Council for ProjectHealth Design.
Paul is an elected member of the Institute of Medicine, and has served on numerous boards related to healthcare and health informatics. He is a recipient of the AMIA Don E. Detmer Award for Health Policy Contributions in Informatics; was named an Innovator and Influencer by Information Week, a Healthcare Innovator by Healthcare Informatics, a Health Care Heroes Awardee by San Francisco Business Times, and a HIT Men and Women of the Year by Healthcare IT News. Modern Healthcare named him one of the 100 Most Powerful People in 2009 and 50 Most Powerful Physician Executives in 2011.
Paul received his B.S. and M.S. in electrical engineering at Stanford University, and his M.D. from the University of California, San Francisco. He is a board-certified practicing internist, and consulting associate professor of medicine at Stanford University School of Medicine.
Christina is responsible for developing community partnerships to expand the linkAgesTM program and promoting community engagement through outreach activities and events. Christina has ten years of experience in nonprofit program development and management. Prior to PAMF, she worked with U.S-based and international NGOs to develop and implement community-based health programs addressing lifestyle-related health factors and infectious diseases, for diverse populations. Christina holds a Master’s degree in Public Health from Loma Linda University.
Dominic joined the Innovation Center team in July 2014. As Program Intern, he assists in developing and implementing the linkAgesTM Advocates internship for college students. His interest in aging populations stems from his volunteer experiences with hospice care, as well as research conducted at the Levine Cancer Institute. Dominic earned a BA in Hispanic Studies with High Honors from Davidson College.
Andrew joined the Innovation Center in February 2014 from the Mayo Clinic where he led multidiscplinary research projects in the fields of bioinformatics and clinical informatics. His recent work there involved developing new machine learning approaches to predict patient outcomes in liver transplantation surgery and to identify key mutations from cancer genome sequencing data. In his role at the Innovation Center, Andrew will support the team by developing data analysis tools and predictive models for both the linkAgesTM and EMPOWER-H programs.
Andrew earned his Ph.D. degree in Physics from the University of Wisconsin – Madison. After completing postdoctoral work in computational biology at the University of California – San Diego he worked as a researcher at The Scripps Research Institute and Oak Ridge National Laboratory.
Albert Chan, MD, MS
Albert serves as both the Chief Medical Information Officer of the Palo Alto Foundation Medical Group and Medical Director of My Health Online (formerly known as PAMFOnline) for Sutter Physician Services. He works together with his fellow physicians and other clinical colleagues to continually optimize use of PAMF’s electronic health records and patient use of online patient services.
Albert received his medical degree from the University of California, San Diego. He earned a bachelor’s degree with honors in Biological Sciences and a master’s degree in Biomedical Informatics from Stanford University.
Program Development Specialist
Tiffany joined the Innovation Center team in January 2013 with a background in health and public policy. Her previous work focused on multiple topics, ranging from health education in the Office of the Surgeon General to health care policy and reform at the National Opinion Research Center and in the Office of Senator Dianne Feinstein. Aside from policy work, Tiffany also focused on social and private sector approaches to health and environmental issues through programs at the Stanford Graduate School of Business and the Stanford Earth Systems Program.
In her role at the Innovation Center and with linkAgesTM, Tiffany works on a team to drive and support linkAges program development and provides operational support to the linkAges TimeBank.
Tiffany holds a master’s degree in Earth Systems, focusing on Environmental and Food Policy, and bachelor’s degree in Human Biology, concentrating on Health and Environmental Policy, from Stanford University
Martin Entwistle, MBA, MB ChB, FRCSEd
Executive Director, MPower
From 1996-2008, Martin was founder and CEO of Enigma CKM Inc., a vendor that created a patented clinical decision support system, which was acquired by PAMF in 2008. Since joining PAMF, he has served as senior director of Personalized Healthcare Programs, developing programs that help to improve patients’ health by creating personalized health plans based on the patient’s individual situation and health. Martin qualified as a physician (MB ChB) from Birmingham University, UK and earned specialization in orthopedic surgery (FRCSEd), and MBA from Cranfield University, UK.
Linette Fung, MBA, MS
Linette joined the Innovation Center from McKinsey & Company, where she worked as a management consultant in their health care practice. At McKinsey, her work with health and hospital systems focused on achieving growth through innovative approaches to partnering, service line optimization and provision of care for seniors and patients with chronic disease.
Linette holds a master’s degree in Molecular and Cellular Physiology from Stanford University, a master’s in business administration from the UCLA Anderson School of Management, and a bachelor’s degree in Molecular and Cellular Biology from Harvard University.
Erica joined the Innovation Center team in January of 2015 with a background in medical anthropology. As the team Medical Ethnographer she is working with community members to better understand the experiences of older adults and the challenges that they face affecting their health and well-being. Medical ethnography allows deeper insight into the context and behaviors that impact people’s lives, which helps the team to design innovations that enhance health at the individual and community levels.
Erica earned her Ph.D in Anthropology from the University of Alabama in 2007. Prior to her work at the Innovation Center, she conducted cross-cultural research on pregnancy and birth experiences of women in the US, Italy, and Mexico while she was a professor of anthropology and women’s and gender studies.
Linda Klieman, ANP, MSN, RN, CDE
Nurse Care Manager
Linda has been with the Palo Alto Medical Foundation since 2007. She has been working in the field of cardiovascular risk reduction for over 10 years. Here at PAMF, she has worked on the EMPOWER D study, and is currently part of the PAMF Innovation Center. She volunteers at Peninsula Healthcare Connection and has participated in the Diabetes Taskforce at PAMF. Prior to coming to PAMF, she worked at the Stanford Prevention Research Center on several cardiovascular risk reduction projects. Linda has a bachelor’s degree in biology from the University of Vermont, a bachelor’s degree in nursing from Columbia University and a master’s of science in nursing from the University of California San Francisco.
Diane returned to PAMF to join the Innovation Center team in January 2014 as a nurse practitioner with the EMPOWER-H Program. She has a background in advanced practice nursing specializing gerontology, public health, medical nutrition therapy, diabetes education and management, and cardiovascular risk reduction. Previously, Diane worked as a gerontological nurse practitioner at the VA Medical Center, San Francisco and served as Diabetes Educator Coordinator and Clinical Dietitian at PAMF for many years.
Diane holds a master’s of science degree in Nursing from the University of California, San Francisco, a master’s degree in Public Health from Loma Linda University and a bachelor’s of science degree in Dietetics from the University of California, Davis. Diane is also a registered dietitian and certified diabetes educator.
Brooke came to PAMF in 2012 after working as a producer, illustrator and graphic designer at Apple Inc. Brooke brings a wide variety of creative skills to PAMF’s Innovation Center team with experience ranging from conceptual design, illustration and animation to advertising and brand design. Prior to her time at Apple, Brooke served as art director for Eaglevision Productions where she created advertising, branding, video, event and marketing programs for clients including Agilent, Sun Microsystems, VeriSign, Adobe, Extreme Networks and Hilton Hotels Corporation.
Shaun McElrath MPM, MBA, PMP, joined the Innovation Center as a Project Manager for the Personal Health Care Program. Shaun joined PAMF after a career at Genentech, where she was instrumental in implementing the Google application suite of products, with a focus on change management and end-user training. As a member of the Genentech Commercial Training and Development Team, she became a certified innovation facilitator and delivered innovation workshops to the sales and marketing teams. She enjoys helping her PAMF teammates understand and appreciate the value of project management within health care.
Shaun holds a master’s in Project Management and MBA from Keller Graduate School of Management and is PMP (Project Management Professional) certified.
Christina joined the Palo Alto Medical Foundation last year in 2011 when she was hired to work as a Project Specialist for the EMPOWER-H research study. She is also part of the PAMF Innovation Center team. Before coming to PAMF, she worked at Advogent (formally Cardinal Health) in Saratoga as a Project Manager for high level Pharmaceutical companies, managing their Speakers Bureau, programs and conferences.
Vivian joined the Innovation Center in May 2014. As part of the linkAges team, she supports the development and implementation of the Center’s community-based programs through active and sustained engagement. Her passion for community health stems from her experiences working with underserved minority communities throughout the Bay Area and internationally. Vivian holds a BA in Psychology with a minor in Global Poverty and Practice from the University of California, Berkeley.
Vandana has broad-ranging experience with social sector practice in the US and India and specializes in envisioning and implementing sustainable models for organizational growth. Prior to joining the Palo Alto Medical Foundation, she led strategic development at The Health Trust, a Silicon Valley-based operating foundation advancing solutions for health equity and wellness. Vandana has also consulted on strategic planning, program design and board development with several Bay Area organizations and continues to serve in an advisory role to build scale and capacity for nonprofit organizations.
At PAMF’s Druker Center for Innovation, Vandana leads strategic initiatives to support deployment of the Center’s work including partnerships, program modeling & operations, communications and a student internship program.
Vandana has a graduate degree in Mass Communications from the Mass Communications Research Center in New Delhi and an undergraduate degree in Psychology from Delhi University.
Executive Project Specialist
Prior to joining the Innovation Center team, Liz worked as a project coordinator for PAMF’s Personalized Health Care Program and as an implementation coordinator for the Electronic Health Record (EHR) Team. Liz earned a bachelor’s degree in Health Sciences from California State University, East Bay.
Martha Simmons, M.D., PhD
Clinical Content Manager
Martha has been with the Palo Alto Medical Foundation since early 2012 when she joined the Innovation Center as Clinical Content Manager for Personalized Healthcare Programs. In this position, she is responsible for creating, organizing and updating the growing range of clinical information used within these programs.
Martha received her BA in Biology with Honors from Grinnell College, and her MD and PhD in Pharmacology from the University of Iowa. She trained in Anatomic Pathology and Neuropathology at the University of California San Francisco, after which she joined the faculty as an Assistant Clinical Professor. As part of that role, she created new interactive online content for the Neuropathology portion of the Medical School’s Brain, Mind and Behavior course. She has also worked in medical communications and has taught classes in emotional and physical wellness through the Institute for Health Solutions.
Marketing Communications SpecialistJohn joined the Innovation center in April, 2014, contributing expertise in marketing, business development and communications. He has worked for diverse companies in the entertainment, media, online, information and non-profit industries, for such companies as Windham Hill Records, America Online, Dialog, Stanford University and Community School of Music and Arts. John’s forte is creating imaginative marketing strategies, utilizing media, social media, special events and partnerships to drive visibility and engagement for organizations.
John holds a BA in geography from California State University, Chico, and graduate studies in geography at San Jose State University. He is also a professional photographer.
Senior Software Architect
Since 2000, Charles has been innovating the EpicCare Ambulatory and MyChart applications to place PAMF at the forefront of health information technology. His initial foray into clinical applications development was at Hewlett Packard Labs, where he developed biomedical applications, including an electronic health record system and an ICU care management software system. Later, he joined the Epic Systems Research Institute, developing clinical applications currently used in EpicCare.
Charles earned a bachelor’s degree in Applied Physics at the California Institute of Technology and a doctorate in Applied Physics from Harvard University. After post-doctoral work at Harvard Medical School and Massachusetts Institutes of Technology, Charles worked as a physics professor at Brandeis University.
Paul Tang, MD, MS
Vice President, Chief Innovation and Technology Officer
Friday, Sept. 27, 2013 was a big day for the Palo Alto Medical Foundation’s linkAges Program as more than 200 representatives of community, social service, private and not-for profit organizations gathered at our public symposium, Aging and Community: Redefined!, to discuss strategies to support our senior community – growing 10,000 people stronger every day.
The Palo Alto Medical Foundation (PAMF), one of northern California’s largest providers of primary and specialty care, is redefining itself as a community partner to address non-medical determinants of health and support aging in community. Our linkAges Program now has partnerships with 17 local nonprofits, neighborhood associations, faith-based organizations, and businesses who understand the value of working together to rebuild community.
The keynote speaker at the event, Bruce Chernof, CEO of SCAN Foundation, a foundation that focuses on the wellbeing of seniors, explained that “chasing diseases is not where the money is. It’s about addressing functions. Function is about the quality of life. That solution is going to be based in the community.”
A stakeholder panel representing corporations, social services, and other foundations confirmed Dr. Chernof’s claim that in order to successfully address the needs of seniors, we must partner with the community.
I had the opportunity to describe PAMF’s Successful Aging program and our linkAges system. The receptivity by community leaders and seniors to the disruptive ideas we proposed was heartwarming and gratifying. We described the way PAMF is redefining our role as an organization that not only delivers healthcare, but also partners with the community in raising the health and well-being of residents, particularly seniors. Many participants stepped up to our request for their engagement by signing up for timebanking, offering to donate their services and their time, and providing funding.
PAMF is proud to be taking an activist role, joining with our community partners, to implement a solution that empowers and supports seniors aging in community!
We invite you to join us in this effort!
linkAgesTM Ecosystem Partnerships:
linkAges deploys through a network of partners that include health systems, local government, community-based organizations, faith-based, civic and neighborhood groups, local leaders and community members who support linkAges as adopters or outreach partners. Through this collaborative model, linkAges activates diverse communities to achieve scale and impact.
We leverage the inherent talent and expertise present in the Silicon Valley community and seek technology partnerships to identify and develop solutions that help us advance our work.
Foundations and Philanthropists:
Philanthropic contributions and Foundation investments provide us with critical support for our work. Foundations who invest in our work also serve as peer-reviewers and help us build knowledge and expertise through shared intellectual capital. Funding may support system development or program expansion.
Click here to find out how you can become part of the solution for creating a community support network.
With Baby Boomers turning age 65 at a rate of 10,000 a day, speakers at a forum titled “Aging and Community Redefined – A Vision for the Future,” explored ways that health systems can partner with communities to ensure that seniors can live independent and fulfilling lives in the communities they love. The symposium was sponsored by the Palo Alto Medical Foundation (PAMF) and held in Mountain View, CA, on September 27, 2013.
The keynote speaker, Dr. Bruce Chernoff, CEO of the SCAN Foundation and Chair of the Federal Commission on Long-Term Care, said that we should be thinking not just about disease but about function. “Diseases only gets you half way there. Function is about the quality of life. It’s about how we help our older, valued, community and family members be fully connected. That’s actually a good thing for the medical system.”
Dr. Chernof said that 70 per cent of those over 65 will need some form of long-term services and support and will need it for an average of three years. “This is going to happen to all of us. It’s going to be part of our lives. Most of us are going to need a little bit of help at some point in our lives. We should be working on a solution and the solution is going to be based in the community.”
Dr. Paul Tang, who directs the Druker Center for Health Systems Innovation, focusing on disruptive innovations, told the audience, “the traditional role of health care organizations serving only as sick-care providers ignores the important opportunity to sustain the social and mental wellbeing of seniors. For example, loneliness – perceived social isolation – not only impacts seniors’ feeling of wellbeing, it leads to higher death and disability rates, compared to those who are not lonely.” He cited evidence that seniors who are lonely have a 45% increased mortality rate at 6 years compared to seniors who are not lonely and they have twice the rate of loss of ability to perform normal activities of daily living. Tang said, “PAMF is developing a system we call linkAges to rebuild communities and redefine how seniors age in America. We’re taking a disruptive-solution approach, addressing those social determinants of health that are outside the traditional medical delivery by creating a broad, community-based model to support successful aging in community.”
In an unprecedented commitment by a large health system, PAMF, one of the region’s largest providers of primary and specialty care, has partnered with 17 local nonprofits, neighborhood associations, faith-based organizations, and businesses to offer a community-based response to address non-medical determinants of health and support successful aging. Earlier this year, the linkAges pilot was introduced in the city of Mountain View, CA, which was chosen because it is home to a population of diverse ethnicities and incomes, active partner agencies, a supportive City Council, strong neighborhoods, active faith-based organizations, and a significant senior population. PAMF will be expanding the geographic scope of linkAges in surrounding areas in 2014.